PSA Lab

[turnerdc@gmail.com]

We have just recently in the last few weeks started having PSA lab test denied from Palmetto for dx R97.20 (elevated psa). It is saying non-medical necessity. Is anyone else having this problem?

 

[TammyHF]

Per CMS website:
"Please note that due to this being the first regular ICD-10 code update since the partial code freeze October 1, 2011, (there were limited new codes introduced in fiscal years 2012, 2013, 2014, and 2015), and the voluminous number of new codes involved, the Medicare shared systems will split implementation of the new codes over the January 2017 and April 2017 quarterly updates. While the implementation dates will be in January and April, the effective dates of the new codes will still be October 1, 2016. All deleted codes will not be valid for payment after September 30, 2016. Contractors will be instructed to adjust claims brought to their attention."
https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/LabNCDsICD10.html
I spoke with a rep for WPS she said that they have to 12/5/2016 to update their system but CMS would publish the new lab NCD till January 2017. She said they are not planning on doing a mass readjustment at this time and suggested a test claim be submitted after 12/5/2016 per the MLN MM9806. But I haven’t seen any payments for R97.20 yet.

 

[TammyHF]

I got my first payment with R97.20 as the only diagnosis for PSA for WPS Medicare contractor.